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Globus pharyngeus : a review of etiology, diagnostics, and treatment

Järvenpää, Pia
2018-08

Järvenpää , P , Arkkila , P & Aaltonen , L-M 2018 , ' Globus pharyngeus : a review of
etiology, diagnostics, and treatment ' , European Archives of Oto-Rhino-Laryngology , vol.
275 , no. 8 , pp. 1945-1953 . https://doi.org/10.1007/s00405-018-5041-1

http://hdl.handle.net/10138/304112
https://doi.org/10.1007/s00405-018-5041-1

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European Archives of Oto-Rhino-Laryngology (2018) 275:1945–1953
https://doi.org/10.1007/s00405-018-5041-1

REVIEW ARTICLE

Globus pharyngeus: a review of etiology, diagnostics, and treatment

Pia Järvenpää1   · Perttu Arkkila2 · Leena‑Maija Aaltonen1

Received: 17 April 2018 / Accepted: 14 June 2018 / Published online: 25 June 2018
© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Abstract
Globus is a non-painful sensation of a lump or a foreign body in the throat, and it frequently improves with eating. Although
globus is a common symptom, only little is known about the etiology, and the causes have remained controversial. Previ-
ously, globus was labelled as a hysterical symptom. However, nowadays, the research has been mainly focused on somatic
causes and it is suspected that the etiology is complex. Because of the unclear etiology, the diagnostics and treatment are
varying, predisposing patients to possible unnecessary investigations. This review presents the current literature of globus:
its etiology, diagnostics, and treatment. In addition, a special aim is to discuss the rational investigation methods in globus
diagnostics and present a diagnostic algorithm based on recent researches.

Keywords  Globus pharyngeus · Globus diagnostics · Etiology · Treatment

Introduction UES pressure and in esophageal motor disorders [7]. Com-

Globus (Latin globus = globe), the feeling of a lump in the
throat, is a general symptom especially affecting women
under 50 years. Among apparently healthy adults in a com-
munity, globus can affect 21.5–46% [1, 2]. The etiology of
globus is disputable, leading to disagreement regarding how
these patients should be examined and treated. Historically,
globus was considered a psychological problem [3]. Cur-
rently, it is obvious that the causes are rather multiform,
although some patients’ symptoms may have a psychological
background. Gastroesophageal reflux disease (GERD), lar-
yngopharyngeal reflux (LPR), esophageal motor disorders,
and improper upper esophageal sphincter (UES) function are
suggested to cause globus [4–6]. However, studies demon-
strating the causal relationship between these disorders and
globus are mainly inadequate.
Currently, methods suitable for investigation of the
esophageal etiology of globus are available. High-resolution
manometry (HRM) provides more accurate diagnostics on
* Pia Järvenpää
pia.jarvenpaa@fimnet.fi
1
Department of Otorhinolaryngology, Head and Neck
Surgery, University of Helsinki and Helsinki University
Hospital, Helsinki, Finland
2
Department of Gastroenterology, University of Helsinki
and Helsinki University Hospital, Helsinki, Finland
bined esophageal multichannel intraluminal impedance and
pH monitoring (MII-pH) distinguishes acid and non-acid
reflux, as well as allows detection of possible proximal
reflux, and has the ability to define whether refluxiates are
liquid, gas, or mixed [8]. Moreover, a transnasal esophago-
scopy (TNE) enables a well-tolerated endoscopy to be per-
formed under local anesthesia [9]. Recently, some studies
have used these new methods to examine the esophageal
background of globus.
Common treatment for globus has been to explain the
benign nature of the symptom to the patient [10]. An out-
patient examination has been suggested to be sufficient in
patients with typical globus [11]. However, many globus
patients undergo further diagnostics such as radiographic
swallowing examinations. It has been proposed that atten-
tion and reassurance alleviate globus symptoms, but con-
trary results also exist [12, 13]. Accordingly, some investi-
gations may be performed to exclude a malignancy and to
ensure both the patient and the clinician that the symptoms
are harmless.
The aim of this review is to present the literature related
to globus pharyngeus and to update the current knowledge of
its etiology, diagnostics, and treatment. The review discusses
the rational investigation methods based on recent research
and presents an algorithm to guide in globus diagnostics.

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1946
Definition and prevalence
Globus was already recognized in the time of Hippocrates.
Historically, it was considered to be a hysterical symptom
(Greek hystericus = related to uterus), globus hystericus,
especially affecting anxious women [3]. In 1968, Malcom-
son observed that not all globus patients were hysterical or
female and suggested use of the term globus pharyngeus
[14].
Overall, globus seems to be equally prevalent in healthy
women and men [15]. However, the symptom affects women
age 50 and below three times more than men, and women are
also more likely to seek medical advice regarding the symp-
tom [15–17]. Globus represents about 4% of new referrals
to ear, nose, and throat (ENT) clinics [17, 18]. However, in
one study, up to 78% of patients at other than an ENT clin-
ics have been found to suffer from globus-like symptoms
measured by the Glasgow–Edinburgh throat scale, but had
never sought health care for those symptoms [19].
Etiology
Gastroesophageal reflux disease
Gastroesophageal reflux disease (GERD) is defined as a con-
dition in which the reflux of gastric contents causes difficult
symptoms and/or complications [20]. The causative role of
GERD in globus is disputable. In 1968, Malcomson was the
first to connect globus and GERD using barium swallow to
show reflux in over 60% of globus patients [14]. Thereafter,
Cherry et al. demonstrated that 10 patients out of 12 reported
globus after acid was supplied to the distal esophagus [21].
Moreover, GERD was suggested to be a major cause of the
symptom in up to 58% of globus patients with abnormal pH
results [4]. However, based on an ambulatory pH study, in a
retrospective setting, findings of GERD were not more com-
mon in patients with globus than in controls [5].
In the past decade, the association of globus symptoms
with GERD has been clarified. Globus is now considered
to be a manifestation of a functional esophageal disorder,
and when a patient has a globus symptom directly related
to reflux, the patient is considered to have GERD, even if
other objective GERD findings are lacking [10]. It has been
speculated that globus patients may have non-acid GERD,
which would explain why they do not benefit from PPIs.
However, a prospective study of Nevalainen et al. indicated
that globus patients without reflux symptoms did not have
acid or non-acid GERD in 24-h MII-pH [22]. Nevertheless,
with the use of new advanced investigation methods, it is
expected that knowledge of the causative role of GERD as
an etiological factor for globus will increase.
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European Archives of Oto-Rhino-Laryngology (2018) 275:1945–1953
Laryngopharyngeal reflux
Laryngopharyngeal reflux (LPR) is considered to be an
extraesophageal indication of reflux disease. In LPR, the
retrograde flow of gastric contents comes in contact with the
mucosa of the upper aerodigestive tract [23]. In contrast to
esophageal mucosa, the larynx and pharynx are very sensi-
tive to gastric reflux, so patients with LPR are more likely
to have laryngeal symptoms, such as throat cleaning, but do
not necessarily have symptoms of GERD, which requires
frequent and prolonged exposure to reflux [4, 24, 25]. In
addition, it has been proposed that reflux could cause glo-
bus through vagus nerve. This was demonstrated in a study,
where acid perfusion to the distal esophagus raised the UES
pressure causing globus sensation [26]. Although hoarse-
ness, cough, and throat cleaning are usually considered to
be LPR symptoms, these symptoms are unspecific and may
be caused by other disorders as well [27]. A study by Gooi
et al. found that up to 48% of otolaryngologists considered
LPR to be highly related to globus [6]. However, the pos-
sible connection of globus and LPR has not been clarified.
The laryngeal findings indicating LPR are also unspecific
and prone to under- and overestimation [28, 29]. Moreover,
the prevalence of these mucosal findings suggesting reflux
is reported as high as 70% in normal volunteers [30]. There-
fore, the diagnostic criteria for LPR have not met with uni-
versal consensus [6].
Abnormal upper esophageal sphincter function
In 1974, Watson and Sullivan investigated globus patients
and controls with manometry and found that cricopharyn-
geal sphincter pressure was statistically significantly higher
in patients with globus [31]. However, Cook et al. found in
their study of 7 globus patients and 13 healthy controls that
globus patients’ resting upper esophageal sphincter (UES)
pressure and its response to stress were normal [32]. In a
study of 32 globus patients and 24 healthy volunteers, no
statistical difference was found in UES resting pressure [33].
Nonetheless, a strong association between hypertonicity of
the UES and globus in conventional manometry was found
in one retrospective study [5].
Currently, high-resolution manometry (HRM) is a more
precise diagnostic method in the evaluation of the esopha-
geal sphincter pressure [7]. Kwiatek et al. used HRM to
quantify the timing and magnitude of respiratory variation of
the UES and discovered that in globus patients, respiration-
related change in the resting UES pressure was significantly
amplified compared to controls and GERD patients, but the
clinical meaning of that finding is unclear [34]. However,
other studies have not found the association between globus
and elevated UES pressure upon HRM. In one retrospective
European Archives of Oto-Rhino-Laryngology (2018) 275:1945–1953 1947
study, UES basal and residual pressures between globus and
dysphagia patients, as well as normal controls, were evalu-
ated. The study showed that mean UES basal and residual
pressures were normal in both globus patients and normal
controls [7]. Moreover, a study by Choi et al. showed that
globus patients did not have elevated UES pressure upon
HRM, compared to normal controls and patients with GERD
[35]. In addition, a prospective study by Nevalainen et al.
found that UES pressure was not elevated in globus patients
upon HRM [22].
Esophageal motor disorders
Only a limited number of studies have evaluated esophageal
motor disorders as a possible cause or contributing factor
in globus. In 1989, Wilson et al. demonstrated that there
were no differences between globus patients’ and controls’
esophageal body motility upon manometry [36]. In another
study, 67% of globus patients’ esophageal manometry was
abnormal; however, the most frequent finding (29%) was
a nonspecific esophageal motility disorder [37]. In their
prospective study, Knight et al. evaluated patients with sus-
pected extraesophageal manifestations of GERD, such as
globus. Upon esophageal manometry, seven globus patients
out of 12 had nonspecific esophageal disorders, while two
had a hypertensive lower esophageal sphincter (LES) and
three had normal results [38]. Consequently, the esopha-
geal motor disorders most often diagnosed in globus patients
have been nonspecific and made using conventional manom-
etry. In 2016, one prospective study used a more accurate
method, HRM, and it revealed an esophageal motor disorder
in half of the globus patients diagnosed by the Chicago clas-
sification, the worldwide accepted algorithmic scheme to
analyze HRM studies [22, 39]. However, these motor disor-
ders were mainly minor and were similar to those that can
also be detected in healthy subjects [40]. Two of their 21
globus patients had a diagnosis of a major motor disorder:
one with absent peristalsis and one with esophagogastric
junction outflow obstruction, a subtype of achalasia [22]. In
the future, it is expected that the use of HRM may clarify
the possible role of esophageal motor disorders in globus
patients. However, based on Rome IV criteria if the globus
patient has a diagnosis of a major esophageal motor disorder,
the term globus should not be used [41].
Psychological factors and stress
Historically, the term globus hystericus was used to suggest
a psychological origin to the symptom, and in fact, many
studies have shown this. In a study by Deary et al., globus
patients were significantly more depressed than controls
[42]. Globus patients had also more stress and severe life
events throughout the year compared to controls in another
study [43]. Middle-aged women with globus were signifi-
cantly more likely to experience neuroticism, to be less
extroverted, and to have psychological distress, such as anxi-
ety, low mood, and somatic concerns [18]. Furthermore, up
to 96% of globus patients felt more symptoms when a highly
emotional state occurred [1].
However, in one Finnish study, globus patients and the
general population had a similar prevalence of psychiatric
disorders [37]. In addition, in a study by Moser et al., mean
scores were similar for anxiety, depression, hysteria, and
hypochondria in globus patients compared to general medi-
cal outpatients [44]. In contrary, in a study by Tang et al.,
globus patients in China reported more often psychological
and sleep disorders than controls [2]. Although the symp-
tom’s complex causes are accepted, it is still labelled as code
F45.8, meaning somatoformic disorder, in the international
classification of diseases, 10th edition, (ICD-10) [45].
Other causes
Conditions causing irritation or inflammation in the phar-
ynx and larynx, such as pharyngitis and postnasal drip, may
increase local sensitivity and cause globus [46]. In addi-
tion, globus may be linked to salivary hypofunction, and
anticholinergic medication causing xerostomia was found to
be a risk factor for globus in one cross-sectional study [47].
Anatomical causes, including tongue base hypertrophy and
a retroverted epiglottis touching the posterior pharyngeal
wall, have been considered as local factors inducing globus
[48, 49].
Some studies have investigated thyroid pathology and
globus. One-third of patients with thyroidal mass experi-
enced globus-like symptoms before thyroid surgery [50].
In one prospective study, thyroid nodules larger than 3 cm
located anterior to the trachea were associated with globus
[51]. However, thyroidal findings, such as nodules, are com-
mon coincidence findings in healthy subjects, so their causa-
tive role in globus requires more investigation.
In 2016, a prospective study showed that in 24-h MII-
pH, supragastric belching was diagnosed in globus patients
more often than in controls with reflux [22]. Belching is a
physiological event to release the intragastric air that one
has swallowed. However, a supragastric belch is generated
when a rapid suction of air into the esophagus is expelled
before it reaches the stomach. Some studies suggest a rela-
tionship between supragastric belching and GERD [52].
Nevertheless, supragastric belching in globus patients is a
novel finding. Different mechanisms for how a supragastric
belch is created have been described. A patient may con-
tract pharyngeal muscles to draw the air into the esophagus
or breathe in through a closed glottis [53]. Speech therapy
techniques have been demonstrated to alleviate symptoms in
patients with supragastric belching [54]. It is possible that
13

1948
some globus patients may contract their pharyngeal muscles
inappropriately because of their lump sensation, which may
lead to supragastric belching. In addition, other functional
causes may induce globus sensation. Globus sensation might
be associated to vocal load that can induce voice disorders
[55]. One study showed that some patients with persistent
globus suffered from coexisting voice problems but they did
not recognize that themselves [56]. Authors encouraged ask-
ing for possible voice related problems from globus patients
more actively.
To exclude malignancy, many patients undergo further
investigations. One retrospective study of 699 patients
showed that typical globus symptoms were not hiding
malignancy behind the symptom at the initial visit, whereas
five patients with atypical symptoms revealed malignancies
[11]. In a study by Rowley et al., none of the 74 globus
patients developed an upper aerodigestive track malignancy
during the 7-year follow-up. However, the study was based
on a questionnaire, and if a patient noted they were symp-
tomatic, re-examination was performed [57]. Moreover, in
a study of Järvenpää et al., their national Cancer Registry
data confirmed that during the 3-year follow-up, none of
the 76 globus patients developed a malignancy in the upper
aerodigestive tract or in the head and neck area, of which
globus could have been an early symptom [58].
Examinations used in globus diagnostics
Because the etiology of globus is unclear, uniform inves-
tigation strategy is lacking. Taking a careful clinical his-
tory is essential to determine whether a patient should be
referred for further investigation, such as a radiological
examination or direct esophagoscopy [59]. However, glo-
bus patients without other symptoms are mainly diagnosed
based on their history and a clinical examination, including
neck palpation and nasolaryngoscopic examination [10].
Pathological findings in globus patients can be detected by
a clinical examination with fiber-optic nasoendoscope [11].
Further investigations are not recommended when a patient
has typical globus [10].
Neck ultrasound
Neck ultrasound is occasionally used in globus diagnos-
tics. However, studies evaluating its usefulness are lacking.
There are a few studies, which have assessed neck ultrasound
findings in globus patients, but they have investigated only
thyroid pathology [50, 51]. Järvenpää et al. reviewed the
medical records in their tertiary care ENT clinic of 76 globus
patients and it revealed that neck ultrasound was performed
on half of their globus patients [58]. However, it was only
useful in one patient who already had a palpable finding of
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European Archives of Oto-Rhino-Laryngology (2018) 275:1945–1953
an enlarged thyroid, which the ultrasound confirmed to be
a goiter. Other neck ultrasounds were within normal limits
[58].
Videofluorography
Videofluorography is quite often used in globus diag-
nostics, although its benefit has not been proven [60]. In
1982, Ardran examined 300 globus patients with a cinera-
diographic examination: patients swallowed a fluid barium
suspension, showing that there was no visible lump in the
throat [59]. In addition, a modified barium swallow study
with esophagogram showed no benefit in globus diagnos-
tics [61]. Moreover, Luk et al. reviewed barium swallow
pharyngoesophagographies of 908 globus patients and 86%
had totally normal results [62]. Authors concluded that
the examination has limited diagnostic value and is, there-
fore, not recommended for globus patients; patients under
30 years old, in particular, had no findings. As inline with
other studies, Järvenpää et al. showed that videofluorography
had no benefit in globus diagnostics [58].
Endoscopy
Rigid endoscopy has been the gold standard in otorhi-
nolaryngological practice when an endoscopic examination
is needed. However, because it is an invasive investigation, it
requires general anesthesia and the risk for esophagus perfo-
ration during the diagnostic endoscopic procedure has been
reported to be up to 1.2% [63]. Rigid endoscopy has not
been shown to be useful in globus diagnostics. Nonetheless,
a survey concerning ENT consultants indicated that 61% of
respondents used rigid endoscope in globus diagnostics [60].
A retrospective study of 250 globus patients examined with
rigid endoscopy showed that no malignancies and the status
of the larynx, pharynx, and upper esophagus were entirely
normal in 87% [64].
Transnasal esophagoscopy (TNE) allows examining the
upper aerodigestive tract with a thin endoscope without
sedation. Shaker, a gastroenterologist, published the initial
report of TNE in 1994 [65]. However, Aviv et al. were the
first to publish a study of unsedated TNE in a laryngologi-
cal practice [66]. The procedure is performed on a sitting
patient, and after a local anesthetic is applied to the nasal
cavity, the thin endoscope is passed transnasally [67]. TNE
enables examination of the nasopharynx, hypopharynx, and
larynx before the endoscope is passed into the esophagus,
and a working channel provides an opportunity for taking
biopsies [67]. TNE has been found to be safe and patients
tolerate it well [67–70]. Globus is considered to be one of
the indications for TNE [67, 71]. However, in one prospec-
tive study, TNE was performed by both an otorhinolaryn-
gologist and a gastroenterologist together and also included
European Archives of Oto-Rhino-Laryngology (2018) 275:1945–1953 1949
investigation of the stomach and the beginning of the duode-
num, but the examination showed no benefit in globus diag-
nostics [22]. In that study, 10% of globus patients had endo-
scopic esophagitis defined by the LA Classification system
[22, 72]. However, one study among a normal population
without reflux symptoms showed that esophagitis was diag-
nosed in 9.5%, using gastroscopy [73]. Moreover, the biop-
sies, including those from the hypopharynx, did not reveal
any additional findings, such as eosinophilic esophagitis in
globus patients, in that sample [22]. Thus, studies have not
shown that rigid nor flexible endoscopy is useful in globus
diagnostics.
Manometry
Previously, a conventional manometry with five-to-eight
pressure sensors was a standard investigation method used
when esophageal bolus transit pathology was suspected [74].
However, patients’ symptoms and manometric findings are
considered to be poorly associated [75]. Currently, HRM
gives more precise information about an abnormal bolus
transport, esophageal motility disorders, and UES pressure
[7, 74], and it has recently been studied in globus diagnostics
[7, 34, 35]. However, recent findings upon HRM do not con-
firm the association between globus and elevated UES pres-
sure nor esophageal motor disorders, and therefore, HRM is
not recommended to be routinely used in globus diagnostics.
pH monitoring and 24‑h multichannel intraluminal
impedance
Previously, esophageal pH monitoring was a gold standard
for investigating esophageal reflux events in GERD diag-
nostics [8]. However, it was not able to detect weakly acidic
or non-acidic reflux. Multichannel intraluminal impedance
(MII) detects all reflux events: liquid, gas, or mixed [8, 76].
Moreover, when MII is combined with pH monitoring, it
allows for detection of acid and non-acid reflux episodes and
for analysing associations between a patient’s symptoms and
MII-pH findings [8, 77]. Recent findings, however, do not
support the association of globus and GERD if patients do
not suffer from concomitant heartburn [22]. As MII allows
detecting aerophagia and supragastric belching, its use in the
future might clarify whether globus and these disorders may
be connected in some patients [22].
Treatment
Because the etiology of globus is controversial, there is no
strategy regarding how to treat globus patients. PPI medica-
tion is often prescribed, because it has been suggested that
globus may be related to GERD and LPR. Because exact
GERD diagnostics require invasive and expensive examina-
tions, empirical PPI therapy to diagnose and treat possible
reflux is common. GERD responds well to PPI medication,
but LPR’s response to this medication varies and may require
higher doses and longer treatment periods [78, 79]. One pro-
spective, uncontrolled study demonstrated no changes in gene
expression of cytokines related to inflammation when biopsies
were taken from the posterior larynx tissue before and after
a 10-week therapy of PPI [80]. In addition, a meta-analysis
concluded that using high-dose PPIs are no more effective than
placebo in the treatment of laryngopharyngeal symptoms pos-
sibly connected to GERD [81]. Moreover, placebo has been
as effective as PPIs in resolving globus symptoms [82, 83].
When concomitant with disorders such a major depres-
sion or panic disorder, anti-depressants have been beneficial
in resolving the globus symptoms as well, though study sam-
ple sizes were small [84, 85].
Globus patients with a thyroidal mass experienced
improvement after thyroid surgery [50]. Moreover, globus
patients with an epiglottis touching the posterior wall of the
pharynx became asymptomatic after partial epiglottectomy
[49]. However, both these studies lacked controls. Conse-
quently, it is impossible to determine the operations’ pos-
sible placebo effect as all surgical procedures may, them-
selves, have a curative effect and spontaneous recovery
cannot be excluded completely.
Reducing laryngopharyngeal tension with neck and
shoulder exercises, and relaxation techniques with voice
hygiene and voice exercises improved 92% of globus
patients’ symptoms in one uncontrolled study [86]. In a
sample of 36 globus patients, a speech and language pathol-
ogist (SLP) treated half of the globus patients with exer-
cises to relieve laryngopharyngeal tension, while controls
were only given reassurance by a nurse. After 3 months,
patients in the SLP group had significant improvement in
their symptoms compared to the control group [12]. How-
ever, whether globus patients only benefit from attention,
rather than the SLP’s therapy, remains ambiguous. In addi-
tion, one prospective study demonstrated that globus patients
experienced recovery from their symptoms during a 4-month
follow-up after an ENT physician had investigated them and
they had undergone some further diagnostic procedures with
normal findings [56]. This result suggests that some glo-
bus patients may benefit from assurance of the symptom’s
benign nature: however, this should not lead to unreasoned
further examinations.
Prognosis
In globus patients, rapid symptom relief is often unlikely.
During a long follow-up period of an average of 7.6 years,
55% became asymptomatic and 45% had persistent
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1950 European Archives of Oto-Rhino-Laryngology (2018) 275:1945–1953

Fig. 1  Diagnostic algorithm for Causality? Palpaon finding

globus patients E.g. Cyst of
Consideraon of in the neck / Neck ultrasound
vallecula
operave treatment goiter
Consultaon of
Problems related phoniatrician / speech
Yes to voice and language
pathologist
Globus
paent’s* Dry mucous Humidificaon of the
Findings in ENT- membranes, thick nose and throat,
mucus drinking enough water
examinaon
No
PPI-medicaon, reflux
*Feeling of a lump or a Heart burn self-care, EG/TNE if
foreign body in the throat, necessary
no dysphagia or pain
Instrucons, contact to
Muscle tension
general praconer
No other
symptoms Instrucons, contact to
Stress
general praconer

Informaon about the Consideraon of

Belching, difficult
symptom’s bening nature EG/TNE and 24 h MII-
symptoms
pH, manometry

ENT=ear, nose and throat, EG=esophagogastroscopy, TNE=transnasal esophagoscopy, PPI=proton pump inhibitor, MII-pH=mulchanel
intraluminal impedance and pH-monitoring

symptoms [57]. In a study with a shorter follow-up, an aver-
age of 27 months, 50% of patients became asymptomatic or
experienced symptom relief [87]. Male gender, short dura-
tion of the globus symptom, and no other throat symptoms
were associated with rapid resolution of symptoms [87]. In
a study by Järvenpää et al. globus patients received a ques-
tionnaire concerning their present symptoms 3 and 6 years
after the initial visit at ENT clinic [58]. At both follow-ups,
approximately half of the patients reported that they were
asymptomatic or that they had fewer symptoms than at the
initial visit [58]. However, almost half of the patients felt
that their symptoms were the same at follow-ups [58].
Discussion
The recent literature confirms that not only one cause can
explain a globus patient’s symptoms, but also the back-
ground is multifaceted. PPIs have been widely used to treat
globus, perhaps as a trial to diagnose silent reflux. However,
the current literature does not support the assumption that
GERD is the main cause for globus. In addition, high-dose
PPIs are no more effective than placebo in the treatment of
globus. As PPIs may have long-term side-effects, the use of
this medication requires justification. However, if the patient
has concomitant heartburn, the diagnostics and treatment
should direct to GERD.
Neck ultrasound is not useful in globus diagnostics if
neck palpation is normal. In addition, globus patients do
not benefit from videofluorography as they lack swallowing
difficulties. Currently, new investigation methods, such as
HRM and 24-h MII-pH, enable more accurate diagnostics
and further studies will clarify whether supragastric belch-
ing, aerophagia or major esophageal motor disorders are
overrepresented in globus patients. This knowledge would
also enhance the available treatment options, since treat-
ment until now has mainly been to give reassurance to the
patients. However, these new investigations are not recom-
mended to be used in clinical routine.
Based on the literature, globus patients without alarming
symptoms, such as pain or swallowing difficulties, and who
have no findings in ENT examination including nasolaryn-
goscopic examination and neck palpation, require no further
examinations. However, analysing patient history carefully
may reveal a globus patient’s concomitant voice problem,
stress or tension in the neck, and in these cases, the diagnos-
tics and treatment should focus on these issues. Most of the
patients suffer from mild and intermittent globus symptoms
and it is known that many patients’ symptoms alleviate with-
out any treatment. The most important thing is to explain the
patient the symptom’s natural course and advise to contact
again if the symptoms become severe or progressive, or if
other symptoms such as pain or dysphagia occur.

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European Archives of Oto-Rhino-Laryngology (2018) 275:1945–1953 1951
Conclusion
The patient history and clinical ENT examination are the
most important tolls also in globus diagnostics. Following a
diagnostic algorithm may be helpful to decide how to pro-
ceed with diagnostics (Fig. 1). Although some examinations
are performed to convince the patient, and sometimes the
clinician, that the globus is harmless, it is assumed that a
patient will be satisfied if the clinician explains why further
examinations are not necessary in most of the cases.
Compliance with ethical standards  cohort study of 122 adult patients presenting to an otolaryngolo-
Conflict of interest  All authors have no conflict of interest.
Human and animal rights statement  This article is a review article
within which there are no human participants or animals. Informed
consent is not available in this article.
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